IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm

IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm
JEOPARDY! Click Once to Begin IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm To change the question and answer slides, select the question or answer text box and type in your own questions and answers. To play, click on a question on the game board to go to that question. The house icon will take you to the game board and the question mark icon will take you to the answer slide. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

JEOPARDY! Stop bugging me Nail it Sexy legs Bubble- rap “It’s not a tumah” Derma-what? 100 100 100 100 100 100 200 200 200 200 200 200 300 300 300 300 300 300 400 400 400 400 400 400 500 500 500 500 500 500 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Daily Double Graphic and Sound Effect!
DO NOT DELETE THIS SLIDE! Deleting it may cause the game links to work improperly. This slide is hidden during the game, and WILL not appear. In slide view mode, copy the above (red) graphic (click once to select; right click the border and choose “copy”). Locate the answer slide which you want to be the daily double Right-click and choose “paste”. If necessary, reposition the graphic so that it does not cover the answer text. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-100 49-y/o woman several-day hx of pruritic lesions on the abdomen. Noticed upon return from business trip to a large northeastern city. Didn't see any bugs in the hotel. Husband not itching and has no visible lesions, although he shared the same room and bed. No new meds or exposures to other persons with similar rashes. Medical hx unremarkable, takes no meds. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-100 Which of the following is the most appropriate treatment? A. Oral doxycycline B. Oral ivermectin C. Topical permethrin cream D. Topical triamcinolone acetonide cream Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Topical triamcinolone acetonide cream Dx: Bed Bugs (Cimex lectularius)
Itch: topical TAC, antihistamines. Spont resolution in days. Characteristic grouping linear pattern; series of bites close together. Small punctum or bite mark in center. May be bitten while visiting infested locations; may unknowingly bring the bedbugs home in their luggage. Varied response in different individuals; possible for different persons sharing the same room to have reactions ranging from no visible marks to larger, urticarial wheals. Bugs do not actively infest the skin, pediculicides not indicated. Can become secondarily infected if scratched. bites lacking surrounding cellulitis do not require treatment with antibiotics, such as doxycycline. Infestations are growing problem, esp in large cities where infestations have been found in many public places including hotels, theatres, offices, and even department stores. Bedbugs have not, to date, been convincingly shown to be a vector of communicable disease. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-200 82-y/o man w/ 6-wk hx of intensely itchy rash on trunk and extremities, worse at night. No new exposures or meds. PMH: Alzheimer’s, lives in assisted care facility. Meds—donepezil, MVI. PE: scratching intermittently; lesions in finger webs, wrists, torso, umbilicus. Fine linear scale in a few areas. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-200 Which of the following is the most appropriate diagnostic test to perform next? A. Complete blood count B. Microscopic evaluation of skin scrapings C. Serum tissue transglutaminase level D. Skin biopsy for direct immunofluorescence microscopy Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

B. microscopic eval of skin scrapings Dx: scabies
Dx by microscopic identification of the mite, feces, or eggs. Scrape many lesions. Unexplained itch, rash; institutionalized pt. Scrapings of affected skin are placed on a microscope slide with a drop of either potassium hydroxide (KOH) or mineral oil and viewed under low power. Because of the relative paucity of live mites present on most persons, multiple lesions should be scraped to maximize the chances of finding the mite. The diagnosis should be suspected in any person with unexplained itching and a rash, particularly in institutionalized patients among whom scabies infestation can be easily spread. The classic areas of involvement include the finger web spaces, wrists, umbilicus, nipples, axillae, genitals, and buttocks; however, the characteristic small, excoriated papules, papulovesicles, and 3- to 5-mm linear burrows can develop on any area of skin, including palms and soles. Scabies may infest the scalp of children, but usually does not affect adult scalps. The diagnosis should not be missed because of a lack of burrows or lesions in characteristic areas; some patients have very few lesions. Serum tissue transglutaminase level may be abnormal in patients with dermatitis herpetiformis, which is associated with gluten-sensitive enteropathy, but this condition presents as vesicular lesion usually on extensor surfaces. A skin biopsy may establish the diagnosis if the mite or mite debris is captured in the sample; however, findings are typically nonspecific, and the diagnosis can be missed. Direct fluorescent antibody testing is helpful in patients with autoimmune blistering diseases, but this patient's presentation is not consistent with this disorder. There are no specific immunoreactant findings in scabies infestation, and thus skin biopsy for immunofluorescence testing is not appropriate for this patient. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-300 35-y/o man sores on lips following trip to Caribbean 1 week ago, where he sustained a sunburn followed by painful blisters on the back, face, and especially the lips. Blisters on lips crusted. Otherwise well except for recurrent herpes labialis. Meds: intermittent oral acyclovir. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-300 Which of the following is the most likely diagnosis?
A. Actinic cheilitis B. Allergic contact dermatitis C. Coxsackievirus infection D. Reactivation of herpes simplex virus Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Reactivation of HSV Herpes labialis can be reactivated by UV.
Actinic cheilitis--premalignant condition occurring in persons who have spent a significant time outdoors. It usually affects the lower lips. Contact dermatitis to sunscreen can occur on the lips, but it is usually pruritic (a hallmark of contact dermatitis) or irritating. Coxsackievirus—hand, foot, mouth dz primarily in kids. Intraoral and palmar/plantar lesions. Oral aphthae, fever, sore throat. Spares lips, gingiva (HSV does not). Herpes simplex virus persisting in a latent state in the trigeminal ganglion may reactivate, typically causing a localized cluster of vesicles along the vermilion border of the lip. The vesicles rupture and crust within 24 to 48 hours and heal over the ensuing 7 to 10 days without scarring. Ultraviolet radiation-induced immunosuppression may cause direct reactivation of HSV-1 in the neural ganglia and is thought to be the cause of herpes labialis. This is a fairly common phenomenon, and for those with frequent recurrences, oral antiviral agents given prophylactically as well as sun protection (lip balm with sunscreen) may reduce the frequency and severity of attacks. Actinic cheilitis is a premalignant condition occurring in persons who have spent a significant time outdoors. It usually affects the lower lips. There is blurring of the margins of the vermilion border and the skin with scaling, fissuring, and ulcers that slowly progress over time. Coxsackievirus--The cutaneous lesions are round to oval-shaped flesh-colored papules with a rim of erythema. The oral lesions consist of small aphthae. Fever and sore throat are common. Lesions due to coxsackievirus spare the lips and gingiva and help distinguish it from HSV infection. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-400 20-y/o man single erythematous macule on L arm that rapidly changed to fluid-filled lesions, some of which were cloudy. PE: vitals normal Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-400 Which of the following is the most appropriate topical treatment? A. Bacitracin B. Clotrimazole C. Hydrocortisone D. Mupirocin Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Mupirocin Dx: Impetigo
Staphylococci or streptococci. Tx: cleansing, wet dressings to remove crust, mupirocin treatment of choice. Bullous impetigo--always S. aureus. Systemic spread of the same toxins causes staphylococcal scalded skin syndrome. Most impetigo is nonbullous. Nonbullous impetigo--direct person-to-person contact, spreads rapidly. S. aureus or Streptococcus pyogenes. This pt: localized infection, afebrile; systemic Abx not indicated as first-line tx. Bacitracin--high rate of allergic contact dermatitis. Anaphylaxis reported with prior contact sensitization. If Staphylococcus aureus is the cause, secretion of exfoliative toxin may result in superficial blister formation. Nonbullous: Usually sites of minor trauma. In widespread or complicated cases, oral β-lactamase-resistant antibiotics such as cephalexin can be used. Hydrocortisone--can mask symptoms, worsening the infection. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-500 35 y/o woman w/ recurrent salmon
colored oval lesions on chest, upper back, occasionally itchy. Tried OTC selenium sulfide- shampoo with modest improvement. Lesions reappear every year during hot, humid weather. KOH : “spaghetti and meatballs” pattern Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 1-500 Which of the following is the most appropriate next step in treatment? A. Oral ketoconazole, single dose B. Topical corticosteroids C. Topical ketoconazole D. No treatment Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Topical ketoconazole Dx. Tinea versicolor
aka pityriasis versicolor, a common superficial fungal infection caused by yeast Malassezia furfur (aka Pityrosporum ovale or Pityrosporum orbiculare). Oral therapy avoided as first-line therapy bc abnormalities in liver chemistry tests and drug interactions are common. Data suggest that when systemic therapy is prescribed, longer durations of treatment and higher doses produce greater cure rates. Single doses of oral azole antifungals are less effective than multiple doses over several days or weeks. Although optimal regimens have not been established, the data suggest that ketoconazole, 200 mg/d for 10 days, itraconazole, 200 mg/d for 7 days or 100 mg/d for 2 weeks, or fluconazole, 300 mg/wk for 2 to 4 weeks, can be recommended. Single-dose regimens of ketoconazole, 400 mg, are less effective. The need for retreatment is the norm rather than the exception. Topical corticosteroids may temporarily relieve the pruritus, but would ultimately worsen the infection and allow the yeast to flourish and grow. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-100 30-y/o man w/ nail changes. Induction chemo for AML 1 mth ago. Afebrile, no systemic complaints. Kidney, liver chemistry studies normal. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Beau lines B. Lichen planus C. Median nail dystrophy D. Psoriasis Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Beau lines Chemo induced
Transverse linear depressions in nails from significant systemic stress such as chemo, sepsis. Temporary disruption of nail production in nail matrix. Typically, all nails are involved. Harmless; atypical portion will grow out, be clipped off as nail growth returns to normal. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Lichen Planus pitting, pterygium, onycholysis
Occasionally, all 20 nails rough, longitudinal ridging (“20-nail dystrophy”) Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Median Nail Dystrophy Longitudinal depression or canal in center of nail, down entire length. Typically 1-2 nails; thumb nails prone to this condition Cause: trauma. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Psoriatic nails Psoriasis--pitting, onycholysis, “oil drop” sign
Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-200 25-y/o man w/persistent discoloration on a single nail x 1 yr. Enlarged slowly. No hx trauma. No other nails are affected Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Longitudinal melanonychia B.Hematoma C. Onychomycosis D.Subungual melanoma Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Subungual melanoma Pigmentation extending onto proximal nail fold or other adjacent skin (Hutchinson sign) and a wider diameter of the pigmented area at the proximal area of the lesion, indicating an expanding lesion. a form of acral lentiginous melanoma that originates under the nail; it is commonly seen in patients with darker skin tones. Subungual melanoma may also present as diffuse nail discoloration of a single nail. Longitudinal melanonychia is a common finding in patients with darker skin types. In contrast to subungual melanoma, the pigmentary lines are lighter and of constant diameter. Hutchinson sign is not seen. Multiple nails are often involved. Subungual hematomas are commonly seen secondary to trauma. The color may be dark brown or black, but is often tinged with a slight reddish or violet hue. The discolored area progresses distally as the nail grows out, creating a zone of clearing between the proximal nail fold and the border of the discoloration. Surrounding skin changes (bruising or other injury) should resolve within a few weeks. Onychomycosis (nail fungus) is a common condition and may exhibit a variety of colors including yellow, brown, and dark brown. Multiple nails are generally involved, and prominent subungual debris is often present. Discoloration should not involve the surrounding skin, however. Diagnosis can be made by nail scraping with potassium hydroxide (KOH) examination under the microscope or with culture. Onychomycosis and melanoma are not mutually exclusive, and thus a biopsy is indicated if atypical pigmented findings are present even if the presence of fungus is confirmed. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-300 65-y/o man 10-year hx of painful thickened fingernails. Started on L hand with two nails, gradually spread to all fingernails. Not improved after 3 mths of po terbinafine. PMH: DM2 treated with metformin and glyburide. PE: There are 10 thickened yellowed fingernails with periungual debris. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-300 Which of the following is the most appropriate next step in management? A. Begin fluconazole B. Begin itraconazole C. Obtain nail clipping for histology and culture D. Repeat a second course of oral terbinafine Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Nail clipping for path, cx
Up to 50% of all nail dystrophies are caused by conditions other than fungal infection, the dx should be confirmed before tx initiated. Oral antifungal agents are not without toxicities KOH, cx, PAS of clipping Causes: dermatophytes, yeasts, molds, trauma, lichen planus, psoriasis Onychomycosis is usually characterized by a thickened, yellow or white nail with scaling under the elevated distal free edge of the nail plate. However, periodic acid-Schiff staining of a clipping of the nail has proved more sensitive (85%) than either of the former tests. The test is simple to perform and gives results in a few days. Onychomycosis is usually caused by dermatophytes; however, infection with yeasts and non-dermatophyte molds are becoming more common. Candida species are the most frequent among the yeasts. Fusarium species and other non-dermatophyte filamentous fungi are especially difficult to cure in onychomycosis. Most patients with onychomycosis are asymptomatic and do not require treatment. Patients with fingernail involvement, symptomatic toenail infection, or those with peripheral neuropathy, arterial insufficiency, or diabetes mellitus are predisposed to complications from onychomycosis (such as cellulitis). Oral therapy with terbinafine, itraconazole, or fluconazole is usually necessary for cure. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-400 53-y/o woman rash gradual onset x 2 mths. Scalp pruritus, redness of face, pruritic rash on chest, arms. Started after baseball game where she sat in sun for hours. More fatigued lately, DOE. PE: Violaceous erythema of periorbital face, malar area, nasolabial folds. Difficulty abducting arms above 90 degrees or rising from a chair without using her arms to help. DTRs nl, no obvious joint abnormalities. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Dermatomyositis B. Psoriasis with psoriatic arthritis C. Rheumatoid arthritis D. Systemic lupus erythematosus Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Dermatomyositis Heliotrope rash, Gottron papules.
Psoriasis--pink plaques with silvery scale, elbows, sites of trauma or pressure. No muscle weakness, malar rash, or V-neck erythema. Improved by UV. RA--rheumatoid nodules over extensor joints. No muscle weakness, photosensitivity, malar or V-neck erythema. SLE--malar erythema, can follow sun exposure; rare muscle weakness. No Gottron’s papules. Patients with dermatomyositis also frequently have erythema of the malar area, which classically involves the nasolabial fold. The erythema over the joint spaces of the hands and the clinical image shown are consistent with Gottron sign, which is defined as erythema over the extensor joint spaces. This is in contrast to the more commonly seen sign of dermatomyositis, Gottron papules, which are pink to skin-colored papules over the distal and proximal interphalangeal joints. Lacy or reticulate erythema of the V-neck of the chest, lateral shoulders, and upper back is frequently seen in dermatomyositis and referred to as the “shawl sign.” Dermatomyositis can be exacerbated by sun exposure, and patients frequently notice flares of disease after prolonged periods of ultraviolet light exposure. Psoriasis manifests as pink plaques with silvery scale, typically on the elbows and sites of repeated trauma or pressure. Not associated with muscle weakness, malar rash, or the V-neck erythema noted here. Improved by ultraviolet light exposure. Rheumatoid arthritis can be associated with a number of skin findings, typically rheumatoid nodules, which are subcutaneous nodules over extensor joints. Patients with rheumatoid arthritis would not typically have muscle weakness, photosensitivity, or a malar or V-neck erythematous rash. Although the rash of acute systemic lupus erythematosus can manifest with malar erythema and can also follow sun exposure, lupus rarely causes muscle weakness. Finally, lupus is not associated with Gottron papules. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-500 46 y/o woman 4-day hx intensely pruritic rash on face, neck. Started using new facial moisturizer 1 week prior to onset. Stopped using moisturizer, rash persisted. Tried calamine lotion, no improvement. PMH—neg; takes no meds. PE: poorly defined, red, weepy, eczematous patches on cheeks, neck. Few fine vesicles, some serous crusting. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 2-500 Which of the following is the most appropriate corticosteroid cream for this rash? A. Betamethasone dipropionate B. Clobetasol propionate C. Desoximetasone D. Hydrocortisone valerate Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Hydrocortisone valerate Dx: Allergic contact dermatitis to moisturizer
High-potency topical steroids cause thinning of skin, avoid on face, periorbital, occluded areas (intertriginous folds, axillae, under breasts, pannus), and on atrophic skin where absorption may be enhanced  use low potency. Patient's rash involves face, neck  lower potency steroid safest. Adverse effects: thin skin, striae, hypopigmentation, telangiectasia. Clobetasol propionate--ultrapotent corticosteroid Betamethasone dipropionate, desoximetasone--high-potency Appropriate choice of steroid: consider nature of the skin disease, affected body parts. Patients should be taught to use an adequate amount of corticosteroid to treat the affected skin; however, they should be encouraged to use it only as long as is necessary. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-100 54-y/o woman w/enlarging, painful ulcer medial leg x 3-4 mths. Unresponsive to several courses of po cephalexin. Remote hx DVT L leg. BLE skin feels somewhat thickened. Sensation in feet normal. Toes warm. ABI of left leg is 0.9. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-100 Which of the following is the most appropriate treatment? A. Arterial revascularization B. Contact casting C. Intravenous vancomycin D. Unna boot compression Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Unna Boot Compression Dx: venous stasis ulcer
Compression minimizes vascular HTN, edema. Risk factors: chronic venous HTN, hx of DVT, trauma in affected limb. Classically medial malleolus, surrounding skin thickened with chronic hemosiderin deposition. May be assoc w/ venous stasis dermatitis, which causes affected skin to become red, warm, and possibly tender and mimics cellulitis. Contact casting--to redistribute pressure on plantar feet in neuropathic ulcers. Venous stasis dermatitis vs cellulitis: presence of chronic erythema in both lower legs, the absence of fever or leukocytosis, lack of response to appropriate Abx tx favor non-infectious. Multilayered compression bandages w/inner layer of nonelastic zinc oxide bandage covered by an elastic, self-adherent wrap. Applied from foot to below knee with pressure gradient; higher pressures at ankle and lower foot, progressively less pressure as progress up leg. Commercially available multi-component compression dressings have been shown to be more effective than single component compression dressings. A variety of wound dressings may be used to cover the ulcers under the compression dressing. None have been shown to produce superior results. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Arterial ulcers bony prominences, posterior calf. “Punched-out”, painful, limb may be cool to touch, poor capillary refill. Distal pulses may not be palpable. ABI < than 0.9. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-200 35 y/o man pain, increased warmth, erythema, swelling on RLE x 2 d. No pruritus. Hx tinea pedis, chronic lymphedema in RLE. No meds; NKDA. PE: T100.1 °F; other vital. BMI 30. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Bullous tinea B. Cellulitis C. Contact dermatitis D. Stasis dermatitis Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

B. Cellulitis Rapidly spreading, deep, SQ-based infection, w/ well-demarcated area of warmth, swelling, tenderness, erythema, may have lymphatic streaking, fever, chills. Often secondary to streptococcal or staph infection. On legs, almost never bilateral. Risk factors: hx of cellulitis in same location, chronic leg ulceration, varicose veins, thrombophlebitis, DM2, heart failure, lymphedema, obesity, onychomycosis, tinea pedis. Contact dermatitis--swelling, erythema, warmth, but almost always accompanied by pruritus; vesicles, bullae if severe. Diagnosis is usually clinical. Cultures are usually not necessary and are seldom positive (≤5% of the time). Contact derm: can become secondarily impetiginized. Vesicles and bullae can also be present in exuberant reactions. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Bullous Tinea Also inflammatory, erythematous; usually localized to foot, occ spreads to lower ankle. Clues: scales in a “moccasin” distribution. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Stasis Dermatitis Looks similar to cellulitis when inflammatory, can become secondarily infected; Almost always bilateral and usually not tender. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-300 27-y/o man w/ rapidly progressive ulcer on leg, extremely tender, expanding x 1 week. Started days ago. Initial lesion a “pimple.” 2 mths abdominal pain, frequent BMs, watery stools, occ bloody. PE: afebrile, other vitals nl. No streaking erythema, fluctuance, purulent discharge, expressible pus, or sinus tracts. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Calciphylaxis B. Ecthyma gangrenosum C. Necrotizing fasciitis D. Pyoderma gangrenosum Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Pyoderma gangrenosum
Uncommon, neutrophilic, ulcerative skin disease assoc w: inflammatory bowel disease, RA, seronegative spondyloarthritis, hematologic dz or malignancy, most commonly AML. Lesions tend to be multiple and tend to appear on the lower extremities. They begin as tender papules, pustules, or vesicles that spontaneously ulcerate and progress to painful ulcers with a purulent base and undermined, ragged, violaceous borders. Lesions often exhibit a sharp, “cliff-face” cut-off between normal skin and the ulcer itself. Inflammatory bowel disease is the most common underlying association reported in conjunction with PG. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Calciphylaxis Painful ulcerative process due to ectopic calcification of the arteries feeding the skin. Nearly always in pts w/ ESRD in setting of very high Ca-P products; Reticulated, dusky erythema then ulcerates due to cutaneous ischemia. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Ecthyma gangrenosum From perivascular bacterial invasion of blood vessel walls with secondary ischemic necrosis. Multiple lesions may be present at different stages of development. Pseudomonas aeruginosa Almost always occurs in a significantly immunocompromised pt who is clinically ill. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Necrotizing fasciitis
Rapidly progressive infection of subcutis, often streptococcal or polymicrobial. Critically ill, disease progresses over hours. Extreme pain, dull or dusky skin, potentially with crepitus, and a clinical picture of sepsis. Patient is sick! Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-400 31-y/o woman 2-wk hx slightly tender lesions on anterior shins. Appeared suddenly. No joint pain, fevers, cough, ocular symptoms, GI problems. Recently started OCPs. PE: vitals normal. 6-7 bilateral reddish-brown SQ nodules are present on anterior shins. No fluctuance. Rest of exam normal CXR normal. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-400 Which of the following is the most appropriate next step in management? A. Discontinue oral contraceptives B. Initiate oral acyclovir C. Initiate oral cephalexin D. Initiate oral fluconazole Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. D/C OCPs Dx: drug induced erythema nodosum
Septal panniculitis w/ sudden onset of tender, erythematous nodules on the anterior legs Associated with infections, systemic diseases, or adverse drug reactions, particularly to Abx, OCPs, and hormone therapy. -nonspecific cutaneous reaction pattern caused by inflammation in the fat lobules resulting in a septal panniculitis. It manifests as red-brown nodules on the anterior shins. Cephalexin could be considered in patients with EN where there is a clear suggestion that EN was occurring as a result of a streptococcal infection, as EN may follow streptococcal pharyngitis in particular. There are no historical or physical examination clues suggesting the presence of a streptococcal infection, and cephalexin would not be the antibiotic of choice in a patient with streptococcal pharyngitis. Oral fluconazole could be used to treat fungal illnesses. EN may occur as a cutaneous inflammatory sign in cases of fungal pneumonia, such as pulmonary histoplasmosis; however, that is not suggested by this patient's presentation. In addition, fluconazole is not the optimal antifungal agent for patients with asymptomatic indolent pulmonary fungal infections. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-500 68-y/o man slightly pruritic, occ painful plaques on arms x 1 yr. Skin is now very tight, constant discomfort. 1 yr ago, had MRI w/ gadolinium to eval spinal stenosis and back pain. On hemodialysis for ESRD. Meds: Epo-A, lisinopril, nifedipine, sevelamer, ASA. PE: vital nl. Skin indurated, tight, woody, bound-down texture. Labs: SPEP wnl; ANA neg. Anticentromere Ab neg. Scl-70 antibody Neg Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 3-500 Most likely diagnosis? A. Lipodermatosclerosis
B. Nephrogenic systemic fibrosis C. Scleroderma D. Scleromyxedema Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

B. Nephrogenic Systemic Fibrosis
Gadolinium contrast agents identified as potential cause of NSF in pts w/ CKD. Scleroderma is unlikely given the localization of the skin changes to the arms, lack of sclerosis of the face and perioral region, the lack of involvement of the fingers, and neg labs. Skin biopsy: increased dermal fibroblasts that stain with CD34. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Lipodermatosclerosis
Pts w/ sig. venous insufficiency--can develop a severe fibrosing panniculitis. Darkly pigmented, indurated skin , bound down to subQ. Inverted champagne bottle legs Other signs of chronic venous insufficiency are typically present such as varicosities, dependent edema, and venous ulceration, which are not present in this patient. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Scleromyxedema Rare. Widespread erythematous, indurated skin w/near-confluent fleshy papules; Face, fingers, extremities. Usually assoc w/ a serum paraprotein. SPEP was normal in this case. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-100 65-y/o woman prodrome of pain on tip of nose followed by a painful eruption involving the right periorbital tissue. PE: vitals nl. Grouped vesicles on an erythematous base on the tip of the nose and about the right eye. Which of the following is the most appropriate first step in management of this patient? A. Warm compresses B. Begin ophthalmic corticosteroids C. Begin valacyclovir and obtain urgent ophthalmology consultation D. Bacterial cx and start cephalexin Q9. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Begin valacyclovir, consult ophtho Dx: Ocular Herpes zoster
Medical emergency, requires prompt referral ophthalmology, initiation of antiviral tx. If not tx’d promptly, can cause blindness. Eye redness, rash in the supratrochlear nerve distribution assoc w/ clinically relevant eye dz. DFA or PCR confirm dx; however decision to start antivirals based on H&P, rather than wait for lab testing. Shingles, which is reactivation of varicella-zoster virus, can occur anytime after the primary varicella infection. It often begins with a prodrome of intense pain, and in more than 90% of patients, it is associated with pruritus, tingling, tenderness, or hyperesthesia. One hundred percent of patients who developed moderate to severe eye disease presented with a red eye. Hutchinson sign (zoster eruption on the tip of the nose) was not predictive of clinically relevant eye disease. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-200 22-y/o man w/ lip erosions and new rash on the palms.
Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-200 Which of the following infections is most commonly associated with this skin finding? A. Herpes simplex virus B. Parvovirus B19 C. Streptococcus, group A D. Varicella zoster Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. HSV Dx: erythema multiforme
Erythema multiforme is an acute dermatosis of the skin and mucosae that can be triggered by infections, most commonly herpes simplex virus. Tx: symptomatic, prophylactic antiviral tx. Acute, often recurrent mucocutaneous eruption that usually follows an acute infection, most frequently recurrent herpes simplex virus (HSV) infection. It may also be idiopathic or drug related. Most patients are between 20 and 40 years of age. Lesions range in size from several millimeters to several centimeters and consist of erythematous plaques with concentric rings of color. The dusky center may become necrotic and can form a discrete blister or eschar. Few to hundreds of lesions develop within several days and are most commonly located on the extensor surfaces of the extremities, particularly the hands and feet. Lesions occur less frequently on the face, trunk, and thighs. Mucosal lesions are present in up to 70% of patients and involve the cutaneous and mucosal lips, gingival sulcus, and the sides of the tongue. Mucosal lesions consist of painful erosions or, less commonly, intact bullae. The conjunctival, nasal, and genital mucosal surfaces can also be affected. Patients may have low-grade fever during an EM outbreak. Lesions usually last 1 to 2 weeks before healing; however, hyperpigmentation may persist. Recurrences are common, particularly in HSV-associated infection. Treatment of EM is primarily symptomatic. Systemic corticosteroids may provide symptomatic improvement but may be associated with complications. Antiviral therapy does not shorten the EM outbreak in HSV-associated infection, but continuous prophylactic antiviral therapy may help prevent further episodes. Treatment for bacterial infection-associated EM is appropriate for management of the specific active infection; however, there are no studies that demonstrate that treatment impacts the duration of the EM lesions. Antibiotic therapy is based on identification of an infectious cause. If EM is thought to be due to a new drug, the drug should be discontinued. EM is not caused by streptococcal infection but may be triggered by the antibiotics used to treat this or other bacterial infections. Parvovirus B19 and varicella zoster virus are rarely associated Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-300 64-y/o man in ER for rash x 3d, rapidly spread to most of body. Skin is painful. PMH: psoriasis and asthma. Meds: topical corticosteroids prn, inhaled corticosteroid, salmeterol, albuterol. 1 wk ago, completed 10-day course of oral corticosteroids for an acute exacerbation of asthma. PE: appears ill. T102.0 °F, BP 118/78 mm Hg, P 112/min. > 90% BSA erythematous, widespread coalescing erythematous patches and plaques, with pinpoint pustules coalescing into lakes of pus. Mucous membranes are normal. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Candida albicans infection B. Pustular psoriasis C. Sweet syndrome D. Toxic shock syndrome Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Pustular psoriasis Pts w/ hx of psoriasis txd w/ systemic corticosteroids may develop an acute pustular erythrodermic flare after the systemic corticosteroids are discontinued. Tx: underlying dz (psoriasis in this patient), supportive care. Most common causes of erythroderma: drug eruptions, psoriasis, atopic dermatitis, CTCL Widespread erythema, scaling, and sheets of superficial pustules with erosions are the findings associated with severe pustular psoriasis. Erythroderma, which is present in this patient, is defined as generalized erythema of the skin involving more than 90% of the body surface area. Candida albicans overgrows and causes localized disease in immunocompromised patients or in the presence of warmth, moisture, maceration, antibiotic therapy, or the use of occlusive garments. Cutaneous candidiasis is characterized by red, itchy, inflamed skin. At sites of skin-to-skin contact, lesions have glazed, shiny, and sometimes eroded surfaces and may be characterized by burning. Satellite pustules (yellow, fluid-filled lesions at the edge of the confluent red eruption) are another key physical finding. Toxic shock syndrome is associated with many different skin manifestations, but the initial manifestation is typically a diffuse erythroderma resembling sunburn that involves both the skin and the mucous membranes. Toxic shock syndrome is usually associated with infection, wounds, nasal packs, or menstruation. This patient has no risk factors for toxic shock syndrome, and his clinical presentation with erythematous patches and plaques, pinpoint pustules, lakes of pus, and normal mucous membranes is not compatible with the diagnosis. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Sweet’s syndrome (Acute febrile neutrophilic dermatosis)
More common in adults than children. Majority (50%-80%) of pts have a fever. Arthralgia, myalgia, and arthritis are seen in 30% to 60% of patients. Often considered a reactive syndrome, assoc. with a preceding URI, GI illness; Assoc. w/malignancy in about 10% of pts. First-line tx: systemic corticosteroids. The skin findings are edematous red-purple plaques on the trunk and extremities. They are often painful or burning, not pruritic. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-400 37-y/o woman 24-hour hx of peeling skin. Recently treated for UTI w/ bactrim. Developed fever , red, itchy papules on her torso and extremities. She continued the Abx, rash worsened, skin became painful. No other meds, NKDA. PE: acutely ill, pain. T102.9 °F, BP 100/60 mm Hg, P106, RR20. Skin shears. Erythema, crusting around eyes, lips, open erosions in mouth, vulva Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-400 Patient is admitted to the ICU and aggressive
IVF replacement is begun. Which of the following should be done next? A. Begin intravenous corticosteroids B. Begin topical corticosteroids C. Begin vancomycin D. Obtain a skin biopsy Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. skin biopsy Dx: Toxic epidermal necrolysis
Most important step is stopping the suspected causative medication and initiating supportive care in an ICU or burn unit. Emergent derm consult for evaluation, skin biopsy to ensure appropriate dx and mgmt. This patient has toxic epidermal necrolysis (TEN), a severe and potentially life-threatening skin condition that is most commonly an adverse drug reaction. TEN typically begins with a prodrome of fever, sore throat, or a burning sensation in the eyes 1 to 3 days before skin lesions appear. Skin findings may be characterized by flat, atypical, purpuric, targetoid lesions that coalesce into dusky, poorly demarcated, confluent patches (TEN “with spots”) or may consist of confluent, tender erythema without identifiable individual lesions (TEN “without spots”). The involved epidermis blisters and sloughs, leaving behind denuded dermis. The Nikolsky sign, in which lateral pressure on erythematous skin shears off the skin, is often present but is not pathognomonic for TEN. The mucous membranes are often involved, but this is not required to make the diagnosis. Skin biopsies of sloughing skin may be sent for evaluation by frozen section, providing a confirmatory diagnosis within hours. In the interim, any likely causative medications should be discontinued, and no unnecessary medications should be added. Patients should receive meticulous wound care, management of fluids and electrolytes, nutritional support, and monitoring and treatment of superinfections Topical corticosteroids not appropriate for this acutely ill patient because these agents are unlikely to change the patient's clinical course or provide any comfort benefit. Treatment with systemic corticosteroids is controversial, and most studies suggest their use in the setting of TEN actually increases morbidity and mortality. There is no role for prophylactic antibiotics in TEN. Treatment with antibiotics is appropriate only when there is evidence of infection. This minimizes the risk of developing antibiotic resistance and also avoids exposing the patient to any unnecessary medications. IVIG: It is important to note that all IVIG studies have examined clinical outcomes based on treatment in adults with doses ranging from 0.2g/kg/day to 2g/kg/day for 1-5 days' duration. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-500 79- y/o woman pruritic blisters on chest, abdomen, and lower extremities x 3 -4 weeks' duration. The blisters arise in crops, drain clear yellow fluid, and crust over before healing. No recent illness, feels well. Cannot identify precipitating causes. Takes no new meds, no new topicals, no new exposures to plants. No sick contacts. PMH: Hashimoto thyroiditis; Meds: levothyroxine. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 4-500 What is the best next step? A. Bacterial cx
B. PCR from blister fluid C. Skin biopsy and DIF D. Tzanck prep Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Skin biopsy and DIF Dx: Bullous Pemphigoid
Chronic, vesiculobullous eruption, mainly involves nonmucosal surfaces. Subepidermal tense blisters. Widespread: lower abdomen, inner thighs, groin, axillae, flexural aspects arms and legs. Has been assoc. w/ psoriasis, DM, SLE, pernicious anemia, thyroiditis, polymyositis, RA. Path: Subepidermal blister, DIF + IgG, C3 at BMZ - punch biopsy from blister edge for H&E staining shows level of the blistering and any associated inflammation, and a separate punch biopsy, obtained from perilesional skin several millimeters away from the blister, should be examined for the presence of immunoreactants by direct immunofluorescence microscopy. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-100 75 y/o man asymptomatic, dark brown, irregularly pigmented patch on cheek x 7 yrs; enlarging slowly. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-100 Which of the following is the most appropriate next step? A. Broad shave biopsy B. Cryotherapy C. Single punch biopsy D. Topical 5-fluorouracil Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Broad shave biopsy Dx: Lentigo maligna
Uniformly pigmented, light-brown patch on face or upper trunk in sun-damaged skin, enlarges slowly, variegated in color. Preferred method of bx for most atypical pigmented lesions worrisome for melanoma is excisional biopsy with 2-mm margins. This allows determination of both atypia and depth. 3 reasons why broad shave bx preferred for LM: (1) most in situ or minimally invasive; little risk of transecting base; (2) the atypical cells are not distributed homogenously throughout the lesion; performing a small punch biopsy carries a significant risk of a false-negative result; and (3) cosmetic result superior compared with more invasive techniques. Shave bx--risk of transecting base of the lesion, making accurate determination of the depth difficult; however, LM is an important exception to this rule. For LM: Although an excisional biopsy would not be incorrect from a medical standpoint, most lentigo maligna lesions and their mimics (pigmented actinic keratoses, solar lentigines) are large in diameter and occur on the face. Excisional biopsy would leave undesirable cosmetic result. Although this is an acceptable situation when the diagnosis is indeed lentigo maligna, it is less than optimal to leave a significant cosmetic defect when the diagnosis turns out to be benign or merely precancerous. A single punch biopsy --incorrect, since examination of a limited area of skin in this setting is not very sensitive and may miss the diagnosis; multiple punch biopsies from different areas of the lesion, however, would be an acceptable approach. Cryotherapy or topical 5-FU—No. Would prevent the establishment of correct dx, and application of more definitive tx. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-200 78-y/o man several-year hx of increasing number of irregularly pigmented “moles” on the back. Mostly asymptomatic, some itch, some getting larger. Concerned for melanoma, asking for removal of all. FHX: sister with melanoma at 55 y/o. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-200 Which of the following is the mostly likely diagnosis?
A. Atypical nevi B. Melanomas C. Seborrheic keratoses D. Solar lentigines Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Seborrheic keratoses
Benign waxy, verrucous papules ranging in color from flesh colored, to yellow, to tan, may be irregularly pigmented. Torso, back, btwn breasts, face, scalp. Rare: rapid development of multiple SKs--sign of Leser-Trélat--assoc with malignancy They often start around age 30 years, increase with age, and can number from a few to hundreds of keratoses on a given person. They are benign and do not have a premalignant potential, thus their treatment is usually considered cosmetic unless they become inflamed, itch, or are otherwise irritated. Seborrheic keratoses must be distinguished from atypical nevi and from malignant melanoma. Clinical examination is sufficient in some patients; however, the use of dermoscopy, which incorporates a handheld magnification device, can provide additional diagnostic information about the pigment architecture and pattern. In some patients, a biopsy is needed to distinguish between an atypical pigmented lesion and a seborrheic keratosis. Melanomas can be difficult to distinguish clinically from seborrheic keratoses. They are usually pigmented. They often have irregular borders, whereas the border of seborrheic keratoses is usually well demarcated. Any darkly pigmented or black lesion should be evaluated for melanoma. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-300 75-y/o man w/ asymptomatic smooth papule on his face x 7 mths. Enlarging steadily and periodically bleeds when traumatized. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Actinic keratosis B. Basal cell carcinoma C. Epidermal inclusion cyst D. Melanoma E. Squamous cell carcinoma Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

B. Basal cell Smooth, pearly, asymptomatic telangiectatic papules that grow slowly, but may eventually cause substantial local tissue destruction if not removed. t typically appears on the head and neck of older persons. Sun exposure is the major risk factor. Classic nodular type basal cell carcinomas appear as smooth “pearly” (translucent) asymptomatic telangiectatic papules. They tend to grow slowly and may eventually cause substantial local tissue destruction if not removed. They rarely metastasize. Actinic keratoses are scaly red macules that occur on sun damaged skin, usually in large numbers. They are a precancerous condition and may give rise to squamous cell carcinomas. In contrast to basal cell carcinomas, actinic keratoses are flat and have prominent scale. In fact, it is often easier to palpate them by running one's hand along the surface of the skin than it is to see them. Epidermal inclusion cysts are benign firm subcutaneous nodules that typically have a prominent central punctum. They contain a copious amount of keratinaceous material that is often malodorous when extruded. Melanomas are a malignancy of the pigment-producing cells in the epidermis. Clinically, they are generally darkly pigmented and possess one or more of the “ABCDE” features (Asymmetry, irregular Border, Color variation, Diameter greater than 6 mm, and Evolution/Enlargement). Squamous cell carcinomas tend to be scalier, grow more rapidly, and are occasionally tender. They lack the pearliness and telangiectasias seen in basal cell carcinomas. They also occur in areas of significant sun damage and may coexist with basal cell carcinomas. They are particularly common in the setting of immunosuppression. Squamous cell carcinomas are more aggressive than basal cell carcinomas and have a much higher tendency to metastasize. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-400 45-y/o kidney transplant recipient w/ asymptomatic lesion below his right ear x 4-6 wks. Unsure if it changed in size. Does not itch or bleed, but is occasionally painful. Med: tacrolimus, lisinopril, atenolol, and trimethoprim-sulfamethoxazole. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Fixed drug reaction secondary to trimethoprim-sulfamethoxazole B. Nummular eczema C. Psoriasis D. Squamous cell carcinoma E. Tinea corporis Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

D. Squamous cell Transplant recipients are at increased risk for the development of skin cancer. Immunosuppressive agents increase the risk of malignancy. These skin cancers are more likely to be multiple, occur at a younger age, behave more aggressively with a significantly increased risk of metastasis and death. Skin cancer, including squamous cell carcinoma, basal cell carcinoma, melanoma, and Kaposi sarcoma, are the most common cancers following solid-organ transplantation. Certain immunosuppressive medications confer an elevated risk, whereas some, such as rapamycin, may actually be protective. Fixed drug eruptions (FDEs) are recurrent reactions to repeated exposures to a single agent. They manifest as a rash recurring at the same location each time; classically FDE presents with a purple patch, potentially with some central blistering, that recurs each time a patient takes a certain medication. Although trimethoprim-sulfamethoxazole has been implicated in FDE, the morphology and clinical history of this patient make FDE unlikely. Nummular eczema is a variant of eczematous dermatitis that tends to be circular or coin-shaped and is often somewhat more challenging to treat than typical eczema. The lack of a history of atopy and the single nature of this patient's lesion make eczematous processes unlikely; additionally, nummular dermatitis rarely has a thick scale and should never cause erosions. Psoriasis manifests as a thin pink plaque with silvery scale and often exhibits koebnerization, or the development of lesions at areas of trauma or pressure. Psoriasis lesions tend to develop on the elbows, knees, umbilicus, or gluteal cleft. Tinea corporis would typically present as a pruritic, annular patch or thin plaque with very fine scaling, not thick adherent scaling. Tinea should not lead to erosions, and it is unusual for tinea to cause tenderness. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 5-500 57-y/o man sore on lip x 3 mths.
Former smoker; quit 10 yrs ago. Which of the following is the most likely diagnosis? A. Actinic cheilitis B.Herpes simplex infection C. Impetigo D. Lichen planus E. Squamous cell carcinoma Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

E. Squamous cell carcinoma
Most common type of oral malignancy, generally consists of red plaques or nodules that may be covered with scale, crust, and erosions. Risk factors: smoking, alcohol, sun exposure. Biopsy Biopsy establishes the diagnosis and should be performed as quickly as possible to avoid treatment delays, since lesions arising in these areas are often particularly aggressive. Actinic cheilitis is a chronic erythema and scaling of the lower lip caused by extensive sun damage. It is a precancerous condition, and squamous cell carcinomas may arise within the affected area. Appears as a rash rather than a tumor; however, any bulky area should be biopsied to rule out squamous cell carcinoma. Tx: cryotherapy, topical 5-fluorouracil, or laser ablation to reduce the risk of malignant transformation. HSV--on and around the vermilion lips. Patients often experience a prodrome consisting of tingling or tenderness prior to onset of vesicles. Once the vesicles arise, they rupture to form erosions that are covered by crusts. Resolution occurs within 2 weeks. Recurrences are common. Impetigo is a superficial skin infection characterized by a yellowish, crusted surface caused by Staphylococcus aureus or group A streptococcal bacteria. If S. aureus is the cause, secretion of exfoliative toxin may result in superficial blister formation. Although common in children, it may occur at any age. It does not occur on mucosal surfaces but is frequently seen on adjacent cutaneous skin such as the cheeks, chin, and cutaneous lips. Treatment consists of topical antibiotics; severe cases may require oral antibiotics as well. Lichen planus can affect the lips and buccal mucosa and occasionally may ulcerate; furthermore, squamous cell carcinomas may arise within them. The characteristic feature is Wickham striae, which is a white lacy rash found on the buccal mucosa. Areas of lichen planus are shallow and lack the tangible substance of the lesion that is shown. They also lack scale and crust. Any suspicious lesion arising within an area of lichen planus should be biopsied, however, to rule out an evolving squamous cell carcinoma. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 6-100 27-y/o woman w/ 4-wk hx of wheals, burning sensation w/o pruritus. Each lesion persists x 48 hrs, slowly resolves, leaving a bruise. Meds-- diphenhydramine, hydroxyzine, cetirizine, and oral contraceptives. Mom—SLE. PE: vitals nl. Scattered ecchymoses at sites of fading lesions. No facial lesions, mucous membranes nl. No joint swelling or tenderness. Which of the following is the most appropriate management? A. Discontinue oral contraceptives B. Radioallergosorbent testing C. Skin biopsy D. Thyroid function testing Scattered edematous, indurated, erythematous plaques consistent with wheals. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Skin biopsy Dx: urticarial vasculitis
Lesions persist > 24 hours and resolve with bruising should be biopsied to evaluate for urticarial vasculitis. 50% of pts have underlying autoimmune disease such as SLE. Less frequently caused by meds; has not been associated with OCPs. Many medications may trigger urticaria. Oral contraceptives can cause urticarial eruptions, including chronic urticaria, typically through progesterone exposure. This frequently manifests as a cyclic urticaria. Patients with a clear food or environmental trigger for urticarial eruptions may benefit from radioallergosorbent (RAST) testing; however, this patient is presenting with atypical urticarial lesions with signs and symptoms concerning for urticarial vasculitis. RAST testing plays no role in the diagnosis of urticarial vasculitis. Thyroid function testing is indicated in the evaluation of chronic urticaria, in which patients have regular episodes of urticaria over a period of more than 6 weeks. Given the atypical presentation of this patient's wheals and the lack of historical features or physical examination findings consistent with thyroid disease, testing is not indicated at this time. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 6-200 34-y/o man progressive thickening of neck, axillae. Asymptomatic, but concerned about the cosmetic appearance. Has DM2, HTN, HLD Meds: metformin, lisinopril, simvastatin. BMI 32. No nail changes. No lesions elsewhere. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Acanthosis nigricans B. Allergic contact dermatitis C. Inverse psoriasis D. Lichen simplex chronicus E. Tinea corporis Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Acanthosis nigricans
Skin thickening, velvety hyperpigmentation of intertriginous areas, particularly the axillae and the neck, in obese patients with hyperinsulinemia. Often develop multiple skin tags. Weight loss and improved control of hyperinsulinemia are primary interventions. Some cases associated with malignancy. Allergic contact dermatitis is almost always associated with pruritus, whereas this patient's lesions are asymptomatic. Additionally, lesions of allergic contact dermatitis are typically erythematous and frequently exhibit a well-demarcated border with a sharp cut-off, corresponding to the area of contact with the offending agent. The multiple areas affected and the clinical morphology described make allergic contact dermatitis unlikely in this patient. Inverse psoriasis is psoriasis occurring in atypical areas, affecting the moist intertriginous regions of the axillae and groin, rather than the classic distribution of elbows and knees. Lesions of inverse psoriasis are typically raw, pink-to-red moist patches limited to the skin folds; patients may exhibit signs of psoriasis elsewhere. This patient's lesions are hyperpigmented and display a velvety or thickened surface; that morphology would be atypical for inverse psoriasis. Lichen simplex chronicus is thickening of the skin with accentuation of the normal skin markings, often accompanied by hyperpigmentation, which results from chronic scratching. Lesions of lichen simplex chronicus are typically extremely pruritic, and it would be uncommon for lesions to present bilaterally and symmetrically in the anatomic distribution described. Although patients with severe diabetes mellitus and obesity may be at increased risk for developing tinea corporis, skin lesions of tinea are typically erythematous, scaly, annular patches. Tinea is normally pruritic and does not show a predilection for the neck. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 6-300 22-y/o woman evaluated for acne, had since her teens. Now 2 mths pregnant, acne worsening. Using OTC benzoyl peroxide, no improvement. PMH: neg. Meds: PNV. Which of the following topical drugs is contraindicated in this patient? A. Azelaic acid B. Clindamycin C. Tazarotene D. Tretinoin Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

C. Tazarotene Tazarotene is rated pregnancy category X and is contraindicated during pregnancy. Tretinoin: topical cat. C; oral cat. D Clindamycin, azelaic acid: cat. B Tazarotene, a topical acetylenic retinoid, is indicated for the treatment of acne and psoriasis; however, it is rated pregnancy category X, and as such, its use in pregnancy is absolutely contraindicated. Retinoids, as a class, exhibit antiproliferative effects, help normalize keratinization, and have more recently been shown to have anti-inflammatory effects. They are particularly effective for the treatment of the comedonal component of acne. When taken systemically, retinoids bind to retinoid acid receptors and, if used during pregnancy, can adversely affect morphogenesis of a number of organs. Retinoid embryopathy is a well-recognized syndrome. The real risk of teratogenicity from topical exposure to retinoids is not known, and tazarotene is one of the relatively few pregnancy category X topical medications. Package labeling requires that a negative pregnancy test be obtained before prescribing tazarotene. Tretinoin, a different topical retinoid (all-trans-retinoic acid), is a pregnancy category C drug when used in topical form. Although its use is not contraindicated in pregnancy, the anticipated benefit from the drug should outweigh any potential risk. Most dermatologists avoid using any topical retinoids during pregnancy because of the teratogenicity of the entire class of retinoids. Oral tretinoin, indicated for the treatment of acute promyelocytic leukemia, is rated pregnancy category D. Both topical clindamycin and azelaic acid, a naturally occurring dicarboxylic acid, are rated pregnancy category B and are considered safe for use during pregnancy. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 6-400 59 y/o man 3 mo hx intermittent itching on forearms, described as deep, with burning, tingling sensation. Scratching helps, OTC topical corticosteroids have not. Cooling soothes. Did not notice a rash until he started scratching. Itch worse after being in the sun, but sun exposure does not cause redness or rash. PE: chronic sun damage, hyperpigmentation, solar lentigines. Few excoriations on the forearms, but no significant dermatitis. Sensation normal. DTR normal. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

A. Brachioradial pruritus B. Polymorphous light eruption C. Prurigo nodularis D. Solar urticaria Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Brachioradial pruritis “itch without a rash”
Neuropathic itch linked to abnormalities in C-spine Deep, crawling, or tingling sensation on the forearms, shoulders, and upper back; no visible skin findings. Evaluation of the spine may reveal evidence of osteoarthritis or other structural abnormalities; however, in absence of gross neurologic deficits, surgery unlikely to benefit. Tx: short term: pramoxine, topical analgesics; long term: gabapentin, pregabalin. Because this is not a histamine-mediated itch, antihistamines and corticosteroids are usually unsuccessful in treating the itch. Topical analgesics, such as pramoxine, offer short-term relief. More prolonged relief may be gained with use of gabapentin or pregabalin in some patients. (PMLE) develops skin lesions after exposure to sunlight. A variety of skin lesions may be seen in PMLE, including urticarial wheals, papules, plaques, and vesicles. PMLE usually develops early in the spring, with the first few exposures to sunlight, and can be triggered by intense exposures. Skin lesions, rather than mere itch, are necessary for the diagnosis. Prurigo nodularis --“picker's nodules.” Can develop in itchy skin (from whatever cause) and consists of thickened, lichenified, excoriated papules and nodules in skin that has been repeatedly scratched. Solar urticaria --rare condition, exposure to ultraviolet light causes hives. It can be difficult to distinguish from PMLE. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Notalgia paresthetica
neuropathic itch on the mid, medial back. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Question 6-500 50-y/o man w/ asymptomatic pink-brown rash in axillae x 3 mo. unresponsive to OTC topical corticosteroids. Meds: none. Coral-pink fluorescence under Wood lamp. Diagnosis? A.Candidiasis B.Erythrasma C.Inverse psoriasis D.Tinea Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

B. Erythrasma Well-defined, pink-brown patches w/ fine scale, in moist, occluded skin folds. G+ bacterium Corynebacterium minutissimum. Porphyrins produced by bacteria illuminate bright coral-pink fluorescence Asymptomatic or mild pruritus. Tx: topical abx such as erythromycin or clindamycin. Distinguishing erythrasma from dermatophytosis such as tinea is possible clinically. Scaling in erythrasma is usually diffuse without central clearing as opposed to tinea. Tinea would also show a slowly advancing border with scale, and central clearing can be present. Potassium hydroxide (KOH) testing of skin scrapings will show the segmented hyphae and arthrospores characteristic of a dermatophyte infection. The yield will be highest when the scrapings are taken from the active, advancing border of the lesion. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Cutaneous Candidiasis
Red, itchy, inflamed. Sites of skin-to-skin contact, glazed, shiny, eroded. May be characterized by burning more than pruritus. Satellite pustules. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

Inverse Psoriasis Intertriginous areas, sharp demarcation.
Often mistaken for fungal or bacterial infection b/c no scaling. Improves w/ topical corticosteroids. No improvement with topical steroids in this case. Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD

IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm

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IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm

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