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Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Click Once to Begin JEOPARDY! IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm.

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Presentation on theme: "Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Click Once to Begin JEOPARDY! IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm."— Presentation transcript:

1 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Click Once to Begin JEOPARDY! IM-Derm Board Review Nita Kohli, MD, MPH PGY-4, Derm

2 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD JEOPARDY! Stop bugging me Nail itSexy legs Bubble- rap “It’s not a tumah” Derma- what?

3 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. Daily Double!!!

4 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

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

6 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.

7 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

8 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 1-200

9 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.

10 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

11 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 1-300

12 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).

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

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

15 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.

16 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

17 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

18 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD C.Topical ketoconazole Dx. Tinea versicolor aka pityriasis versicolor, a common superficial fungal infection caused by yeast Malassezia furfur (aka Pityrosporum ovale or Pityrosporum orbiculare).

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

20 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Beau lines B. Lichen planus C. Median nail dystrophy D. Psoriasis Question 2-100

21 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.

22 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Lichen Planus

23 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.

24 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Psoriatic nails

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

26 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Longitudinal melanonychia B.Hematoma C. Onychomycosis D.Subungual melanoma Question 2-200

27 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.

28 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

29 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 2-300

30 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

31 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

32 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Dermatomyositis B. Psoriasis with psoriatic arthritis C. Rheumatoid arthritis D. Systemic lupus erythematosus Question 2-400

33 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.

34 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

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

36 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

37 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

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

39 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.

40 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.

41 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

42 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Bullous tinea B. Cellulitis C. Contact dermatitis D. Stasis dermatitis Question 3-200

43 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.

44 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.

45 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.

46 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

47 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Calciphylaxis B. Ecthyma gangrenosum C. Necrotizing fasciitis D. Pyoderma gangrenosum Question 3-300

48 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.

49 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.

50 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.

51 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.

52 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

53 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 3-400

54 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.

55 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

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

57 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.

58 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

59 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.

60 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

61 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.

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

63 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 4-200

64 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.

65 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

66 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question Which of the following is the most likely diagnosis? A. Candida albicans infection B. Pustular psoriasis C. Sweet syndrome D. Toxic shock syndrome

67 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

68 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.

69 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

70 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD 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 Question 4-400

71 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.

72 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

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

74 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

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

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

77 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.

78 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

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

80 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

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

82 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Epidermal inclusion cyst D. Melanoma E. Squamous cell carcinoma Question 5-300

83 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.

84 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

85 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Fixed drug reaction secondary to trimethoprim-sulfamethoxazole B. Nummular eczema C. Psoriasis D. Squamous cell carcinoma E. Tinea corporis Question 5-400

86 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.

87 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

88 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

89 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

90 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.

91 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

92 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Which of the following is the most likely diagnosis? A. Acanthosis nigricans B. Allergic contact dermatitis C. Inverse psoriasis D. Lichen simplex chronicus E. Tinea corporis Question 6-200

93 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.

94 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

95 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

96 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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.

97 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question Which of the following is the most likely diagnosis? A. Brachioradial pruritus B. Polymorphous light eruption C. Prurigo nodularis D. Solar urticaria

98 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD A.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.

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

100 Template by Modified by Bill Arcuri, WCSD Chad Vance, CCISD Question 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

101 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.

102 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.

103 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.


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